Patients with high blood pressure given combined drug therapy from the start of treatment respond better than patients given single-drug treatment (monotherapy). Furthermore, patients who later switch from monotherapy to combination therapy improve their response, but not to the same level as those who began with combination therapy. The results of the ACCELERATE study are reported in an Article Online First and an upcoming Lancet . The Article is by Prof Morris J Brown, Addenbrooke's Hospital, Cambridge and University of Cambridge, UK, and colleagues from the British Hypertension Society and Novartis.
All patients in the study had high systolic blood pressure between 150 and 180 mm Hg (normal blood pressure is usually below 140 mm Hg systolic). The study compared the drugs aliskiren and amlodipine, with patients assigned to monotherapy with either drug (318 aliskiren, 316 amlodipine) or a combination of both (620 patients) for 16 weeks. After those 16 weeks, those on monotherapy switched to combination therapy while those on combination therapy already continued.
The researchers found that patients given initial combination therapy had a mean 6•5 mm Hg greater reduction in mean systolic blood pressure than the monotherapy groups. At 24 weeks, when all patients were on combination treatment, the difference had decreased to 1•4 mm Hg. Adverse events such as oedema and low blood pressure (hypotension) caused similar numbers of patients (between 14% and 18%) of patients to withdraw from each of the three groups.
The authors say: "ACCELERATE is the first trial to test the medium-term efficacy and safety of full doses of two antihypertensive drugs as first-line treatment for patients with a systolic blood pressure greater than 150 mm Hg, by comparison with sequential add-on treatment with the same drugs."
They conclude: "We believe that routine initial reduction in blood pressure (>150 mm Hg) with a combination such as aliskiren plus amlodipine can be recommended."
In a linked Comment, Dr Ivana Lazich, and Dr George Bakris, University of Chicago Hypertensive Diseases Unit, Department of Medicine, University of Chicago Pritzker School of Medicine, Chicago, USA, say: "ACCELERATE puts into proper context the importance of starting with combination antihypertensives to lower blood pressure towards guideline goals for the general population... A change in guidelines is clearly necessary after the ACCELERATE report."
Prof Morris J Brown, Addenbrooke's Hospital, Cambridge and University of Cambridge, UK. T) +44 (0)1223 336737 or +44 (0)7710 447223 E) m.j.brown@cai.cam.ac.uk
Dr George Bakris, University of Chicago Hypertensive Diseases Unit, Department of Medicine, University of Chicago Pritzker School of Medicine, Chicago, USA. E) gbakris@medicine.bsd.uchicago.edu
The Lancet